Family First Prevention Services Act: Funding and Limits on Congregate Care

1. Sheila A. PiresManaging Partner, Human Service CollaborativeCore Partner, National TA Network for Children’s Behavioral Health Family First Prevention Services Act NTTAC Team Meeting April 22, 2019

2. Family First Prevention Services Act • Two major related goals: • Funding for prevention services • Limits on use of congregate care

3. Family First Prevention Services Act Prevention Services • Allows use of Title IV-E for Prevention Services and Supports (i.e., to prevent placement of children and youth into foster care and placement disruption for children/youth in adoptive or kinship guardian homes) • Effective October 2019 (State Option) • Covers for 12 months: • Services to address mental health challenges • Substance abuse treatment • In-home parent skill-based programs, including parent education, individual, and family counseling • Also allows reimbursement for kinship navigator programs • Also IV-E reimbursement allowed for up to 12 months for child placed with a parent in a licensed residential family-based treatment facility for substance abuse, regardless of whether child meets AFDC income eligibility – became effective Oct 2018

4. Family First Prevention Services Act Prevention Services Eligibility • Eligible populations to receive services: • Parents or relatives caring for children/youth who are “candidates for foster care” – at imminent risk of entering foster care but can remain safely at home with services and supports • Adoptive parents and relative guardians where placement disruption is issue • Youth in foster care who are pregnant or already parents • Eligible children, youth, parents and kinship caregivers are eligible for services regardless of whether they meet the AFDC income eligibility requirements for IV-E reimbursement • Extends to age 23 supports for youth transitioning out of foster care; extends to age 26 eligibility for education and training vouchers (Chafee Foster Care Independence Program)

5. Family First Prevention Services Act Prevention Services • Prevention services and supports must be promising practice, supported practice, or well-supported practice – 50% of expenditures for prevention services must be for well-supported practice • Trauma-informed • Abt Associates, Cambridge, MA – awarded contract for Title IV-E Prevention Services Clearinghouse • IV-E reimbursement also allowed for kinship navigator programs that meet promising, supported or well-supported practice requirements, regardless of whether child meets AFDC income eligibility • Funds also can be used for training and administration related to the provision of prevention services and supports, including data collection and reporting

6. Nov. 30 Program Instruction on Prevention Services First Services Selected for Systematic Review Prevention Services and Programs • Mental Health: • Parent-Child Interaction Therapy • Trauma Focused-Cognitive Behavioral Therapy • Multi-systemic Therapy • Functional Family Therapy • Substance Abuse: • Motivational Interviewing • Multi-systemic Therapy • Families Facing the Future  • Methadone Maintenance Therapy • In-Home Parent Skill-Based: • Nurse-Family Partnership • Healthy Families America • Parents as Teachers • Kinship Navigator Programs • Children’s Home Society of New Jersey Kinship Navigator Model • Children’s Home Inc. Kinship Interdisciplinary Navigation Technologically-Advanced Model (KIN-Tech) 

7. Nov. 30 Program Instruction on Prevention Services • Selected initial programs met two of following conditions: 1) Recommendations from State or local government 2) Rated by California Evidence-Based Clearinghouse 3) Evaluated by Title IV-E Waiver Demo 4) Recipient of a Family Connection discretionary grant 5) Recommendations from federal partners, including SAMHSA • Will select additional services for review on a rolling basis • Will give particular consideration to services recommended by state and local administrators

8. Family First Prevention Services Act Prevention Services Performance and Reporting Requirements • Performance measures and data collection and reporting required • Services provided, expense, and duration for each child • Placement status of child at beginning and end of 12-month service period and whether child enters foster care within two years

9. Family First Prevention Services Act Prevention Services Federal Match • Between Oct 1 2019-Oct 1 2026, there is a 50% Federal IV-E match for prevention services • Beginning Sept 30 2026, Federal IV-E match for prevention services will be the same as the state’s Federal Medicaid match rate • Maintenance of Effort • States cannot spend less than they did in FY 2014 on prevention services, i.e., cannot substitute FFPSA dollars for state and local prevention expenditures

10. Family First Prevention Services Act Congregate Care • Places limits on use of congregate/group care; states can seek two-year delay (2021) but then funding for prevention services also delayed • Residential treatment programs must meet Qualified Residential Treatment Program (QRTP) requirements, including: • Has a trauma-informed treatment model • Has registered or licensed nursing staff and other licensed clinical staff, who are available 24/7 and available to provide services on-site – do not have to be employees of the facility itself • Facilitates family participation • Facilitates family outreach and documents how outreach is made, and maintains contact information for family and kin • Documents how the family is integrated into the child’s/youth’s treatment, including post-discharge, and how sibling connections are maintained • Provides discharge planning and family-based aftercare support for at least 6 months post discharge • Must be licensed and nationally accredited

11. Family First Prevention Services Act Congregate Care • Assessment to determine appropriateness of placement • Must be done within 30 days of placement in a QRTP • Must be done by a trained professional or licensed clinician who is not a state employee or employee of the QRTP – can be waived if state can demonstrate objectivity • Must use evidence-based, validated functional assessment tool (HHS to release guidance on valid tools) • Assessment must be done in conjunction with child’s/youth’s family and permanency team (can include kin, neighbors, clergy, etc.) • More rigorous oversight of children in QRTPs

12. Family First Prevention Services Act – Congregate Care • Children’s Bureau requested states to provide, by Nov. 9, 2018, certification of intent to request a delay of the congregate care requirements (to help Bureau budget for TA) – Certifications are not binding; states have until Sept. 29, 2019 to make decision • FFPSA requirements unlikely to apply to Psychiatric Residential Treatment Programs (PRTFs), which are 100% Medicaid-funded • Unlikely to apply to residential programs funded 100% with state or local general revenue, i.e., no IV-E • Potential to cost-shift to Medicaid and to other systems – importance of taking a coordinated approach • Title IV-E is payer of last resort • There is a requirement that states certify that FFPSA changes will not increase number of youth entering juvenile justice.

13. Family First Prevention Services Act – Federal Guidance • Children’s Bureau (CB) is issuing Program Instructions and Information Memoranda (rather than lengthy regulatory process) – see Oct. 1, 2018 letter from Acting Commissioner Jerry Milner • Most recent guidance – Nov. 30 Program Instruction on Prevention Services and January 2, 2019 letter to State Child Welfare Directors with additional info on criteria for prevention services • By April 2019, Children’s Bureau, via IV-E Prevention Services Clearinghouse, will issue the Prevention Services Clearinghouse Handbook of Standards and Procedures • More detailed description of the revised initial criteria • Procedures for systematic review and re-review • Definitions of key terminology • All programs and services will have to be rated using the Handbook

14. Key FFPSA Takeaways • FFPSA presents opportunities for child welfare, behavioral health and Medicaid to: • Expand mental health and SUD services; • Expand supports to families/caregivers; • Expand training for family-driven, youth-guided practices; • Obtain better data on mental health and SUD services; • Improve the quality of residential care • FFPSA can help to address common cross-agency concerns such as high out-of-home placement rates, high placement disruption rates, insufficient access to effective home- and community-based behavioral health services, challenges to intervening early, and poor performance on quality measures

15. Key FFPSA Takeaways • States also must define terms such as “candidate for foster care” and “imminent risk” Broad versus narrow definitions – examples: Broad: any child/youth whose parent has been referred to the state or local hotline for alleged maltreatment Broad: any child/youth living on the street and/or homeless Narrow: only pursuant to the substantiation of maltreatment is the child/youth a candidate States will have many variations on these

16. Issues and Strategies to Consider • Issue: Parallel children’s behavioral health delivery systems – in child welfare, in Medicaid, in child behavioral health system • Strategy: A coordinated planning and implementation process to ensure maximization and efficient use of federal, state and local resources and to avoid confusion for families and providers • Issue: Inclusion of evidence-informed and promising practices that do not meet manualized EBP standards, e.g., family and youth peer support, mobile response and stabilization services, intensive care coordination using fidelity Wraparound, respite • Strategy: Encourage Children’s Bureau, Abt Associates, and your state child welfare system to include these services

17. Issues and Strategies to Consider • Issue: Different quality criteria and outcome expectations across different types of residential treatment facilities – PRTFs, QRTPs, RTCs funded solely with general revenue • Strategy: Common practice standards, quality and outcome expectations across residential facility types – based on Building Bridges • Issue: Provider capacity to implement home and community-based services and to meet QRTP requirements • Strategy: Coordinated training approach across agencies; partnership approach with providers

18. Issues and Strategies to Consider • Issue: Family and youth engagement and involvement, buy-in • Strategy: Partner with family- and youth-run organizations in planning, development, and implementation • Issue: Further fragmentation • Strategy: Use system of care principles as the framework

19. Key Steps to Take • If not involved already, find out who is leading FFPSA planning in your state child welfare agency and become involved or establish relationship • Encourage cross-system approach to FFPSA planning – to maximize dollars across systems for prevention services and to raise the quality of residential care, regardless of payer • Make the case for inclusion of key services and supports, such as peer support, ICC/Wraparound, mobile response and stabilization, respite - Encourage Children’s Bureau, Abt Associates, and your state child welfare system to include these services • Make the case for use of IV-E dollars for training related to expanding capacity for key services • Use your evaluation data – qualitative and quantitative - to make the case • Make sure FFPSA efforts include partnering with family- and youth-run organizations and leaders in planning, development, and implementation

20. Example of State FFPSA Planning Structure: Virginia Finance Workgroup • Maintenance of Effort(MOE) • Budget Implications(EBS, workforce) • Challenges: Identifying MOE with the guidance feds have provided Evidence-Based Services Workgroup • Survey for EBS in Virginia(currently 400 respondents) • Collaborate with Medicaid, DJJ, DBHDS • Education on Hexagon Tool • Challenges: Delay of federal clearinghouse • Recommendations on defining key terms(candidate for foster care, imminent risk) • Continuum of Prevention Services(Universal vs. Targeted) • Feedback for Development of Federal Clearinghouse • Challenges: Defining “candidate for foster care”, for Virginia this is targeted prevention services Prevention Services Workgroup Appropriate Foster Care Placements Workgroup • Recommendations for QRTP Assessment • Feedback for Development of Federal Foster Home Model Licensing Standards • QRTP and background check Virginia code changes Nina Marino and Laura Reed, Dept of Behavioral Health and Developmental Services and Dept of Social Services

21. TA Network: SAMHSA and Children’s Bureau Interagency Agreement • Providing guidance to Mathematica project to develop toolkits that support blended, braided funding approaches to FFPSA services • Querying states on the status and nature of their FFPSA planning • Developing repository of questions/issues raised by states, providers and others involved with FFPSA planning • Providing guidance to Children’s Bureau related to issues/questions raised that can be answered technically as opposed to those that require a CB policy response • Providing support to the Children’s Bureau related to a “kitchen cabinet” of key stakeholders involved in FFPSA planning • Supporting SAMHSA in provision of evidence for key services such as peer support, ICC/Wraparound, mobile response and stabilization, early childhood consultation

22. Links to Information Family First Prevention Services Act (P.L. 115-123) Information Memorandum on Family First (IM-18-02) Program Instruction – Implementation of Title IV-E Plan Requirement Child Welfare Community Letter – October 1, 2018 Program Instruction – State Title IV-E Prevention and Family Services and Programs Program Instruction – State Requirements for Electing Title IV-E Prevention and Family Services and Programs https://www.cwla.org/wp-content/uploads/2018/12/ACYF-CB-PI-18-09-Attachment-C-Clearinghouse-Initial-Criteria.pdf Program Instruction – Tribal Title IV-E Agency Requirements for Electing Title IV-E Prevention and Family Services and Programs State Child Welfare Director Letter – January 2, 2019 familyfirstact.org/source/american-academy-pediatrics https://www.aap.org/en-us/advocacy-and-policy/state-advocacy/Documents/StateLegislativeActivity-FFPSA.pdf http://www.ncsl.org/research/human-services/family-first-updates-and-new-legislation.aspx